- Email: [email protected]
Document not found! Please try again
Fibrinolytic parameters as an admission prognostic marker of head injury in patients who talk and deteriorate
J Oral Maxillofac Surg 55:1187-l 192, 1997
Abstracts Composite Technique.
Rhytidectomy: Finesse and Refinements Hamra ST, Clin Plast Surg 24:337, 1997
in
cal to human insulin except the positions B28 (lysine) and B29 (proline) are transposed, giving it a more favorable profile, so it can be given before meals. Subcutaneous lispro has higher and faster peak concentrations and similar bioavailability. It has about a 1 hour peak onset and 4 hours duration of action, and can be administered 10 to 15 minutes before a meal. It can also have better control than regular insulin injected 30 to 60 minutes before the meal. It is relatively stable when mixed with either human NPH or human ultralente. Ultralente is not the ideal basal insulin, but is the only one available now. Another long-acting insulin analogue, HOE 901, is in the early stages of clinical evaluation. The authors describe normal (nondiabetic) insulin secretion is divided into basal secretion (0.5 to 1 U/hr) which occurs between meals and through the nights, and stimulated insulin secretion in response to meals (60 to 80 @J/mL from just prior to 30 minutes after a meal, and concentrations returning to basal levels in 2 to 4 hours. Commercial insulin preparations do not have time action profiles that closely approximate normal insulin secretion. Other methods of injection (eg, nasal) have not proven successful. The authors review the history of insulin. -R.E. ALEXANDER
Composite rhytidectomy is an integrated facelift technique that has been developed with the philosophy that every area of the aging face undergoes topographic changes that are created by changes in deep anatomic structures. For complete facial rejuvenation, each of the deep anatomic structures must be repositioned for a uniform harmonious rejuvenation. The goal of harmonious facial rejuvenation is youthful contours of every area of the face, including an elevated forehead and youthful neck contour. Most importantly, the midface must have a narrow, more shallow orbital appearance to be compatible with an improved nasolabial fold and an improved jawline. When including an upper blepharoplasty with the lower blepharoplasty, it is important to first find the medial lower boarder of the orbicularis oculi muscle and follow it laterally. The reason for emphasizing this refinement is to prevent the inadvertent elevation of the zygomaticus minor muscle into the composite flap. If that is done, contracture of the orbicularis oculi muscle may create an unnecessarily wide distribution of smile lines. When operating from above, the surgeon must be careful not to go deep into the zygomaticus major muscle, for innervation of this muscle is from below. The arcus marginalis muscle should be released after dissection of the orbicularis oculi to reverse the skeletonized appearance of the orbit, and prevent the hollow eyes so frequently seen after orbital fat removal. The lateral canthal ligament should be tightened in the older population. Endoscopic browlifts with subcutaneous rhytidectomy do not require a special balance of tension between the two, so either can be accomplished separately. In a composite rhytidectomy, tension and closure should be considered for each specific area. Traction is placed in the appropriate vector to provide the appropriate tension before closure. The improvement in the midface is mainly caused by a vertical movement, and in the lower face and jawline by a superior-posterior movement. When a primary rhytidectomy is performed, repositioning of all the deep elements of the aging face is necessary to maintain harmony in facial rejuvenation. Composite rhytidectomy is of enormous benefit in secondary rhytidectomy when the surgeon’s goals must be to regain harmony, which frequently is lost after conventional rejuvenative procedures.-R.H. HAUC
Reprint
requests
to Dr White:
222 N 23 rd Ave, Y&ma,
WA 98902.
Dobutamine Stress Echocardiography: Stressing the Indications for Preoperative Testing. Bach D, Eagle K. Circ 95:8, 1997 In comparison with nuclear perfusion imagine, stress echocardiography holds the advantage being able to assess anatomy and function as well as resting and stress ventricular systolic function. It is also less expensive than nuclear perfusion imaging. Patients with at least one risk factor should undergo preoperative stress echocardiography. Those risk factors include age greater than 70 years, Q waves of electrocardiogram, angina of any form, diabetes mellitus, or a history of ventricular arrhythmia. The purpose of preoperative stress testing is twofold: 1) to ensure a safe surgery and perioperative period free of adverse cardiac events and 2) to aid in the identification of those patients with poor longterm prognosis that indirectly may lead to treatment and decreased long-term morbidity via treatment of hypertension, ischemia, hyperlipidemia etc, or reconsideration of the proposed treatment.-F.P. IUORNO, Jr
Reprint requests to Dr Hamra: Plastic and Reconstructive Surgery Association, 2731 Lemmon Ave E, Suite 306, Dallas, TX 75204.
Reprints to Dr Bach: UH BlF245-0022, 1500 E Medical Ann Arbor, MI 48109 (e-mail: [email protected].).
Insulin Analogues: New Agents for Improving Glycemic Control. White JR, Campbell RK, Hirsch I. Postgrad Med 101:58, 1997
Center
Dr,
Fibrinolytic Parameters as an Admission Prognostic Marker of Head Injury in Patients Who Talk and Deteriorate. Takahashi H, IJrano T, Takada Y, et al. J Neurosurg 86:768, 1997
Research has been concentrating on finding a more effective means of insulin delivery that emulates physiologic inrulin secretion. Conventional insulin preparations have limited pharmacokinetic profiles, which makes the goal of emulation impossible. Last year, the Food and Drug Administration approved the first recombinant DNA human insulin analogue, Lispro (pronounced “lice-pro”) (Humalog, Lilly Co,). The amino acid composition of this analogue is identi-
The prognosis for severe head injury has traditionally been based on the results of computed tomography scanning, neurological examination, cerebral perfusion pressure, cerebral blood flow, and other tests. None of these has been established as a reliable indicator to predict the outcome of patient at the time of admission, particularly those poor outcome 1187
1188 patientswith progressivebrain injury who “talk anddeteriorate” after admission.This study evaluatedwhetherfibrinolytic parameterscould be reliable indicators of outcome. Plasma levels of cuz-plasmininhibitor-plasmin complex (PIC) andthe D-dimer fraction of fibrin/fibrinogendegradation productsweretaken at admission,within 2 hoursof the injury. In this study, 70 patientsadmittedover a period of 2 yearswere studied.The meanageof the patientswas55.4 years (range, 17-85) and 60% were male. Plasmalevels of both were elevatedandcorrelatedwell to patient outcomes. When plasmaPIC levels were higher than 15 pg/mL or Ddimer levels were higher than 5 pg/mL, 92% of patients died regardlessof their consciousness levels at the time of admission.All patientswith low levels madegood recoveries.GlasgowComaScale(GCS) did not correlatewell with the outcomein manypatients.Four patientswith initial GCS scoresof lessthan five recovered,but five deterioratedand died.Therefore,they do not feel the GCSis a reliableindicator of patientoutcome.In four patientswho dieddespitelow D-Dimer levels, autopsyrevealedthe causeof deathwas a massivesubduralhematomadueto a laceratedsagittalsinus or bridging vein.-ROGER E. ALEXANDER Reprint requests to Dr Takada: Department of Physiology, Hamamatsu University, School of Medicine, 3600 Handa-Cho, Hamamatsu-shi, Shizuoka-ken, 431-31 Japan.
A Controlled Trial of Oral Acyclovir for the Prevention of Stromal Keratitis or Iritis in Patients With Herpes Simplex Virus Epithelial Keratitis. Barron BA, Beck RW, Asbell PA, et al. Arch Ophthalmol 115:703,1997 The objective of this prospective, randomized,doublemaskedstudywasto evaluatethe efficacy of oral acyclovir in preventingstromalkeratitisor iritis in patientswith epithelial keratitis causedby herpessimplex virus (HSV). A total of 287 patientswere enrolled in this trial. Each patient was randomly assignedto receive either oral acyclovir, 400 mg 5 timesa day for 21 days (153 patients),or oral placebo5 timesa dayfor 21 days(134patients).Ophthalmicexaminations were performedweekly for the first 4 weeks,and at 3, 6, 9, and 12 months. Additional examinationswere performedat the onsetof newocularsymptoms.StromalKeratitis or iritis developedin 17 (11%) of the 153patientsin the acyclovir groupcomparedwith 14 (10%) of the 134patients in the placebogroup. The developmentof stromalkeratitis or iritis was more frequent in patients with history of HSV stromalkerititis or iritis in thosewithout sucha history (23% vs 9%). During the trial, HSV epithelialkeratitis recurredin 21 patientsin the acyclovir group and in 16 patientsin the placebogroup. It was noted that patientsin the acyclovir grouptendedto havefewer recurrencesof epithelialkeratitis during the remainderof the 12monthsof follow-up than the patientsin the placebogroup. The authorsconcludedthat there is no support for the hypothesisthat oral acyclovir given during an episodeof HSV epithelial keratitis might preventthe occurrenceof stromalkeratitis or iritis by inhibiting viral proliferation. They also found that, in this trial, the incidence of stromalkeratitis or iritis was lower than previously reportedin the literature, except in patientswith a history of HSV stromalkeratitis or iritis.-I.E. SHAMI Reprint requests to Dr Beck: Jaeb Center for Health Research, 3010 E 138th Ave, Suite 9, Tampa, FL 33613 (e-mail: [email protected]).
CURRENT LITERATURE
Midline Glossectomyand Epiglottitectomy for Obstructive SleepApnea Syndrome. Mickelson SA, RosenthalL., Laryngoscope107:614, 1997 The authorsdescribedtheir experiencein treating OSAS with midline glossectomyand epiglottitectomy. Twelve patients were usedfor the study. All patientshad failure of prior uvulopalatopharyngoplastysurgery with persistant sleepapnea and narrowing of the hypopharynx. Patients underwentphysical examination,fiberoptic laryngoscopy,and polysomnogramstudy before surgery. Postoperatively,patients were scoredutilizing body massindex, apneaindex, respiratorydisturbanceindex (RDI), andlowestoxygen saturation point. Successfultreatment was defined as an RDI lessthan 20. Resultsshowedthat only 3 of 12 patientsrespondedto treatment.The authorsconcludedthat midline glossectomyand epiglottitectomy hasvarying results.They statedthat it is very effective in selectivepatientswith hypopharyngealnarrowing related to macroglossia.-R. HOLLOWAY Reprint requests to Dr Mickelson: ENT Associates, 5555 Peachtree Dunwoody Rd, Suite 201, Atlanta, GA 30342.
Adults Who Snore. Lindblom SS. PostgradMed 101:171, 1997 Snoring, by itself, is a clinical symptom. An estimated 20% of the adult population snores,and in malesover 40 yearsof agethe numberjumpsto 60%. It is conjecturedthat numerousmiddle-agedwomensnoreaswell. Little attention wasgiven to snoringuntil obstructivesleepapneawasbetter understood.Most snorersdo not have apnea,but mostpeople who have apnea persistently snore. Many people who snore have their sleep disruptedand experiencedrowsinessthe next day. Identification of snorersto have obstructive sleep apneais imperativebut it is unclearwhethersnorerswithout apnearequire treatment.In this article, the author outlines an efficient approach to evaluating
snorers to ascertain the
natureof their condition. He reviews the anatomicfeatures behindsnoring,the consequences of snoring(includingdaytime sleepiness, disruption
of social life), and a potential
link with vascular disease.The signs and symptomsand clinical findings of obstructive sleep apneaare reviewed. Asymptomatic snorersdo not requirepolysomnographyunlessfamily problemsare encountered.Symptomaticsnorers requirea sleepevaluationstudy, but the type variesbetween sleepcenters,physicians,and so on. The author favors a split-nightprotocol.The patientis observedandif a predeterminedrespiratorydisturbanceindex valueis reached(usually 30 to 40 events per hour) the study is interrupted and a continuouspositive airway pressurestudy (CPAP) is initiated.Someexpertsdo not like the split-night protocol, however, feeling that data gathered are inadequate for accurate diagnosis.Cost-effectivenessstudiesare lacking. Treatment methods for snoring include behavior modifications (patient positioning, weight loss, exercise regimens, etc), surgical
interventions(uvulopalatopharyngoplasty,uvuloplasty, etc), insertion
of oral devices (it is estimated
that more than
12,000different deviceshave beencreated),andthe institution of nasal CPAP. Laser-assisted uvuloplasty has become popular but lacks data to support any long-term successes
andis not recommended.All oral deviceseither advancethe mandible,lift the soft palate, or pull the tongue forward. Oral appliances appear effective in most nonapneic snorers, but the long-term
compliance
and effects are unknown.
Nasal
CPAP hasshownvarying resultsin studies.It can eliminate
Abstracts Composite Technique.
Rhytidectomy: Finesse and Refinements Hamra ST, Clin Plast Surg 24:337, 1997
in
cal to human insulin except the positions B28 (lysine) and B29 (proline) are transposed, giving it a more favorable profile, so it can be given before meals. Subcutaneous lispro has higher and faster peak concentrations and similar bioavailability. It has about a 1 hour peak onset and 4 hours duration of action, and can be administered 10 to 15 minutes before a meal. It can also have better control than regular insulin injected 30 to 60 minutes before the meal. It is relatively stable when mixed with either human NPH or human ultralente. Ultralente is not the ideal basal insulin, but is the only one available now. Another long-acting insulin analogue, HOE 901, is in the early stages of clinical evaluation. The authors describe normal (nondiabetic) insulin secretion is divided into basal secretion (0.5 to 1 U/hr) which occurs between meals and through the nights, and stimulated insulin secretion in response to meals (60 to 80 @J/mL from just prior to 30 minutes after a meal, and concentrations returning to basal levels in 2 to 4 hours. Commercial insulin preparations do not have time action profiles that closely approximate normal insulin secretion. Other methods of injection (eg, nasal) have not proven successful. The authors review the history of insulin. -R.E. ALEXANDER
Composite rhytidectomy is an integrated facelift technique that has been developed with the philosophy that every area of the aging face undergoes topographic changes that are created by changes in deep anatomic structures. For complete facial rejuvenation, each of the deep anatomic structures must be repositioned for a uniform harmonious rejuvenation. The goal of harmonious facial rejuvenation is youthful contours of every area of the face, including an elevated forehead and youthful neck contour. Most importantly, the midface must have a narrow, more shallow orbital appearance to be compatible with an improved nasolabial fold and an improved jawline. When including an upper blepharoplasty with the lower blepharoplasty, it is important to first find the medial lower boarder of the orbicularis oculi muscle and follow it laterally. The reason for emphasizing this refinement is to prevent the inadvertent elevation of the zygomaticus minor muscle into the composite flap. If that is done, contracture of the orbicularis oculi muscle may create an unnecessarily wide distribution of smile lines. When operating from above, the surgeon must be careful not to go deep into the zygomaticus major muscle, for innervation of this muscle is from below. The arcus marginalis muscle should be released after dissection of the orbicularis oculi to reverse the skeletonized appearance of the orbit, and prevent the hollow eyes so frequently seen after orbital fat removal. The lateral canthal ligament should be tightened in the older population. Endoscopic browlifts with subcutaneous rhytidectomy do not require a special balance of tension between the two, so either can be accomplished separately. In a composite rhytidectomy, tension and closure should be considered for each specific area. Traction is placed in the appropriate vector to provide the appropriate tension before closure. The improvement in the midface is mainly caused by a vertical movement, and in the lower face and jawline by a superior-posterior movement. When a primary rhytidectomy is performed, repositioning of all the deep elements of the aging face is necessary to maintain harmony in facial rejuvenation. Composite rhytidectomy is of enormous benefit in secondary rhytidectomy when the surgeon’s goals must be to regain harmony, which frequently is lost after conventional rejuvenative procedures.-R.H. HAUC
Reprint
requests
to Dr White:
222 N 23 rd Ave, Y&ma,
WA 98902.
Dobutamine Stress Echocardiography: Stressing the Indications for Preoperative Testing. Bach D, Eagle K. Circ 95:8, 1997 In comparison with nuclear perfusion imagine, stress echocardiography holds the advantage being able to assess anatomy and function as well as resting and stress ventricular systolic function. It is also less expensive than nuclear perfusion imaging. Patients with at least one risk factor should undergo preoperative stress echocardiography. Those risk factors include age greater than 70 years, Q waves of electrocardiogram, angina of any form, diabetes mellitus, or a history of ventricular arrhythmia. The purpose of preoperative stress testing is twofold: 1) to ensure a safe surgery and perioperative period free of adverse cardiac events and 2) to aid in the identification of those patients with poor longterm prognosis that indirectly may lead to treatment and decreased long-term morbidity via treatment of hypertension, ischemia, hyperlipidemia etc, or reconsideration of the proposed treatment.-F.P. IUORNO, Jr
Reprint requests to Dr Hamra: Plastic and Reconstructive Surgery Association, 2731 Lemmon Ave E, Suite 306, Dallas, TX 75204.
Reprints to Dr Bach: UH BlF245-0022, 1500 E Medical Ann Arbor, MI 48109 (e-mail: [email protected].).
Insulin Analogues: New Agents for Improving Glycemic Control. White JR, Campbell RK, Hirsch I. Postgrad Med 101:58, 1997
Center
Dr,
Fibrinolytic Parameters as an Admission Prognostic Marker of Head Injury in Patients Who Talk and Deteriorate. Takahashi H, IJrano T, Takada Y, et al. J Neurosurg 86:768, 1997
Research has been concentrating on finding a more effective means of insulin delivery that emulates physiologic inrulin secretion. Conventional insulin preparations have limited pharmacokinetic profiles, which makes the goal of emulation impossible. Last year, the Food and Drug Administration approved the first recombinant DNA human insulin analogue, Lispro (pronounced “lice-pro”) (Humalog, Lilly Co,). The amino acid composition of this analogue is identi-
The prognosis for severe head injury has traditionally been based on the results of computed tomography scanning, neurological examination, cerebral perfusion pressure, cerebral blood flow, and other tests. None of these has been established as a reliable indicator to predict the outcome of patient at the time of admission, particularly those poor outcome 1187
1188 patientswith progressivebrain injury who “talk anddeteriorate” after admission.This study evaluatedwhetherfibrinolytic parameterscould be reliable indicators of outcome. Plasma levels of cuz-plasmininhibitor-plasmin complex (PIC) andthe D-dimer fraction of fibrin/fibrinogendegradation productsweretaken at admission,within 2 hoursof the injury. In this study, 70 patientsadmittedover a period of 2 yearswere studied.The meanageof the patientswas55.4 years (range, 17-85) and 60% were male. Plasmalevels of both were elevatedandcorrelatedwell to patient outcomes. When plasmaPIC levels were higher than 15 pg/mL or Ddimer levels were higher than 5 pg/mL, 92% of patients died regardlessof their consciousness levels at the time of admission.All patientswith low levels madegood recoveries.GlasgowComaScale(GCS) did not correlatewell with the outcomein manypatients.Four patientswith initial GCS scoresof lessthan five recovered,but five deterioratedand died.Therefore,they do not feel the GCSis a reliableindicator of patientoutcome.In four patientswho dieddespitelow D-Dimer levels, autopsyrevealedthe causeof deathwas a massivesubduralhematomadueto a laceratedsagittalsinus or bridging vein.-ROGER E. ALEXANDER Reprint requests to Dr Takada: Department of Physiology, Hamamatsu University, School of Medicine, 3600 Handa-Cho, Hamamatsu-shi, Shizuoka-ken, 431-31 Japan.
A Controlled Trial of Oral Acyclovir for the Prevention of Stromal Keratitis or Iritis in Patients With Herpes Simplex Virus Epithelial Keratitis. Barron BA, Beck RW, Asbell PA, et al. Arch Ophthalmol 115:703,1997 The objective of this prospective, randomized,doublemaskedstudywasto evaluatethe efficacy of oral acyclovir in preventingstromalkeratitisor iritis in patientswith epithelial keratitis causedby herpessimplex virus (HSV). A total of 287 patientswere enrolled in this trial. Each patient was randomly assignedto receive either oral acyclovir, 400 mg 5 timesa day for 21 days (153 patients),or oral placebo5 timesa dayfor 21 days(134patients).Ophthalmicexaminations were performedweekly for the first 4 weeks,and at 3, 6, 9, and 12 months. Additional examinationswere performedat the onsetof newocularsymptoms.StromalKeratitis or iritis developedin 17 (11%) of the 153patientsin the acyclovir groupcomparedwith 14 (10%) of the 134patients in the placebogroup. The developmentof stromalkeratitis or iritis was more frequent in patients with history of HSV stromalkerititis or iritis in thosewithout sucha history (23% vs 9%). During the trial, HSV epithelialkeratitis recurredin 21 patientsin the acyclovir group and in 16 patientsin the placebogroup. It was noted that patientsin the acyclovir grouptendedto havefewer recurrencesof epithelialkeratitis during the remainderof the 12monthsof follow-up than the patientsin the placebogroup. The authorsconcludedthat there is no support for the hypothesisthat oral acyclovir given during an episodeof HSV epithelial keratitis might preventthe occurrenceof stromalkeratitis or iritis by inhibiting viral proliferation. They also found that, in this trial, the incidence of stromalkeratitis or iritis was lower than previously reportedin the literature, except in patientswith a history of HSV stromalkeratitis or iritis.-I.E. SHAMI Reprint requests to Dr Beck: Jaeb Center for Health Research, 3010 E 138th Ave, Suite 9, Tampa, FL 33613 (e-mail: [email protected]).
CURRENT LITERATURE
Midline Glossectomyand Epiglottitectomy for Obstructive SleepApnea Syndrome. Mickelson SA, RosenthalL., Laryngoscope107:614, 1997 The authorsdescribedtheir experiencein treating OSAS with midline glossectomyand epiglottitectomy. Twelve patients were usedfor the study. All patientshad failure of prior uvulopalatopharyngoplastysurgery with persistant sleepapnea and narrowing of the hypopharynx. Patients underwentphysical examination,fiberoptic laryngoscopy,and polysomnogramstudy before surgery. Postoperatively,patients were scoredutilizing body massindex, apneaindex, respiratorydisturbanceindex (RDI), andlowestoxygen saturation point. Successfultreatment was defined as an RDI lessthan 20. Resultsshowedthat only 3 of 12 patientsrespondedto treatment.The authorsconcludedthat midline glossectomyand epiglottitectomy hasvarying results.They statedthat it is very effective in selectivepatientswith hypopharyngealnarrowing related to macroglossia.-R. HOLLOWAY Reprint requests to Dr Mickelson: ENT Associates, 5555 Peachtree Dunwoody Rd, Suite 201, Atlanta, GA 30342.
Adults Who Snore. Lindblom SS. PostgradMed 101:171, 1997 Snoring, by itself, is a clinical symptom. An estimated 20% of the adult population snores,and in malesover 40 yearsof agethe numberjumpsto 60%. It is conjecturedthat numerousmiddle-agedwomensnoreaswell. Little attention wasgiven to snoringuntil obstructivesleepapneawasbetter understood.Most snorersdo not have apnea,but mostpeople who have apnea persistently snore. Many people who snore have their sleep disruptedand experiencedrowsinessthe next day. Identification of snorersto have obstructive sleep apneais imperativebut it is unclearwhethersnorerswithout apnearequire treatment.In this article, the author outlines an efficient approach to evaluating
snorers to ascertain the
natureof their condition. He reviews the anatomicfeatures behindsnoring,the consequences of snoring(includingdaytime sleepiness, disruption
of social life), and a potential
link with vascular disease.The signs and symptomsand clinical findings of obstructive sleep apneaare reviewed. Asymptomatic snorersdo not requirepolysomnographyunlessfamily problemsare encountered.Symptomaticsnorers requirea sleepevaluationstudy, but the type variesbetween sleepcenters,physicians,and so on. The author favors a split-nightprotocol.The patientis observedandif a predeterminedrespiratorydisturbanceindex valueis reached(usually 30 to 40 events per hour) the study is interrupted and a continuouspositive airway pressurestudy (CPAP) is initiated.Someexpertsdo not like the split-night protocol, however, feeling that data gathered are inadequate for accurate diagnosis.Cost-effectivenessstudiesare lacking. Treatment methods for snoring include behavior modifications (patient positioning, weight loss, exercise regimens, etc), surgical
interventions(uvulopalatopharyngoplasty,uvuloplasty, etc), insertion
of oral devices (it is estimated
that more than
12,000different deviceshave beencreated),andthe institution of nasal CPAP. Laser-assisted uvuloplasty has become popular but lacks data to support any long-term successes
andis not recommended.All oral deviceseither advancethe mandible,lift the soft palate, or pull the tongue forward. Oral appliances appear effective in most nonapneic snorers, but the long-term
compliance
and effects are unknown.
Nasal
CPAP hasshownvarying resultsin studies.It can eliminate